Page 30 - JSOM Summer 2020

balloon occlusion of the aorta (REBOA). These can also be decrease respiratory pain associated with thoracostomy tube
used to measure and trend central venous pressures, blad- or thoracotomy or multiple rib fractures. A transversus ab-
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der pressures, or myofascial compartment pressures. See the dominis plane block can be used as a part of multimodal pain
guideline “JTS resuscitative endovascular balloon occlusion of treatment to attempt early extubation after laparotomy, even
the aorta (REBOA) for hemorrhagic shock CPG.” 28 in patients with a temporarily closed abdomen. 33
Perioperative Anesthetic Considerations Blood Transfusion Capability
Definitive airway control is challenging in the patient with In addition to surgical hemorrhage control, resuscitation with
trauma. It becomes increasingly difficult in the austere envi- warmed blood is the most important intervention the ARSC
ronment and requires a significant commitment of resources, team can perform. Effective resuscitation of the patients with
such as the need for a ventilator, continuous monitoring, and trauma who has sustained massive blood loss consists of simul-
sedation. When intubation is indicated, the timing should taneous hemorrhage control along with resuscitation to correct
be optimized to conserve resources. Even with a depressed trauma-induced coagulopathy, acidosis, and hypothermia.
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Glasgow Coma Scale score, if a patient remains spontaneously Resuscitation with blood products rather than crystalloid or
breathing, it may be preferable to support their respirations vasopressor administration is the standard in trauma care;
noninvasively while resuscitation is initiated. Resuscitation be- calcium administration should be early during the resuscita-
fore induction of anesthesia in an unstable patient may prevent tion. Treatment of acute coagulopathy of trauma is addressed
hemodynamic collapse. Alternative anesthetic techniques such with transfusion of whole blood, plasma, cryoprecipitate, and
as moderate sedation or peripheral nerve block may conserve platelets; however, blood products in the austere environment
resources. With respect to airway management, consider the may be limited and platelets and cryoprecipitate will unlikely
capabilities of the transport personnel, their available respira- be available. Whole-blood administration, preferably stored,
tory and monitoring equipment en route, and the capability of low-titer type O whole blood, provides the most balanced re-
the next level of care. In patients with a potential for airway suscitation and is easier to administer as a single product for
compromise, ensure a definitive airway is established before minimally staffed ARSC teams. The capability to draw warm,
transport. Considerations must be made for supplemental ox- fresh, whole blood from prescreened donors should be opti-
ygen delivery, which can be challenging in this environment, mized. Also, the capability to warm blood products during
an Austere Anesthesia CPG (under development) will address massive resuscitation is required; although there is not always
these issues specifically. standardized equipment to support this requirement, every
effort should be made to ensure these teams deploy with at
Maintenance of Anesthesia least one rapid fluid infuser with warming capabilities. Effec-
The means to administer inhaled agents for the maintenance tive rapid transfusion and warming devices are necessary and
of anesthesia is not likely to be available in the austere setting. require adequate power to support.
Electrical power and inspired gases used to drive vaporizers
are problematic resources to obtain. Draw-over methods could In general, an ARSC team should plan to ideally maintain at
be considered; however, these can be challenging to titrate or least 20 units of whole blood or red blood cells (RBCs) plus
administer when considering variables such as a nonsponta- plasma (20 units of each blood component). Mission require-
neously breathing patient or patient transportation. General ments will also dictate inventory levels of blood (mission sup-
anesthesia using a total intravenous anesthetic (TIVA) is a port versus area support). The ARSC teams must be in regular
more effective way to provide adequate anesthesia and con- communication with the theater Joint Blood Program Officer
serve equipment and resources. Practitioners should have an (JBPO) or Armed Service Blood Program Theater representa-
intimate knowledge of the benefits and limitations of intrave- tive and keep their status updated (as much as possible) in the
nous (IV) anesthetic drugs available to allow for an effective, Theater Medical Data Store to facilitate resupply. ARSC teams
balanced anesthetic. Simple infusion pumps or quantitative must have a well-rehearsed walking blood bank (WBB) capa-
drip sets can automate flow for prolonged infusions and bility. At times, the WBB may rely on the host-nation blood
providers should carefully select and train with their specific supply, depending on the tactical and clinical environment.
equipment. Because TIVA is commonly used in this environ- If using the host-nation blood supply, consideration must be
ment, calculations and concentrations of the most commonly given to endemic disease risk of donors and ability to perform
used drips have to be mastered by providers using this form of rapid tests to mitigate risk. When supporting en route care
sedation and general anesthetic, and the drip rates of propofol, missions, WBB is less feasible and stored blood is required,
fentanyl, and ketamine have to be well understood. depending on operational activity. Frequent communication
with the supporting Blood Support Detachment and JBPO is
Regional Anesthesia Adjuncts essential.
The capability to perform regional anesthetic techniques en-
hances the ARSC team mission. Experience in Iraq and Af- Surgical Airway Management
ghanistan has highlighted the value of early aggressive pain
management in the combat casualty and reinforced the im- Airway obstruction represents 8% of potentially preventable
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portance of multimodal pain management in the perioperative prehospital deaths. Multiple attempts at orotracheal intuba-
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setting. 30,31 The use of regional anesthesia, either in conjunc- tion should be avoided, and providers should maintain a low
tion with or instead of general anesthesia, may reduce the re- threshold to surgically manage the airway. Complex facial in-
sources and personnel required for operative, postoperative, juries require airway management and hemorrhage control for
and subsequent en route care. The risk of masking a develop- temporary stabilization In this circumstance, obtaining an
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ing compartment syndrome must be considered. Ultrasound initial endotracheal tube or cricothyroidotomy is appropriate.
or stimulator-based techniques can be used to perform a va- As mentioned, consider the level of the transport capability.
riety of nerve blocks. Intercostal nerve blocks can be used to Transferring a patient with significant maxillofacial injuries

28 | JSOM Volume 20, Edition 2 / Summer 2020